Today's episode is part 2 of my knee pain recovery and my trip. I talk you through my next steps, how I kept moving and finding strength and the 4 S strategy I employ to counter the 6 F's from Dr. Howard Schubiner.
Today's episode is part 2 of my knee pain recovery and my trip. I talk you through my next steps, how I kept moving and finding strength and the 4 S strategy ( 4 S’s - Soften, Soothe, Settle + Surrender (maybe I’ll discover more S’s as I go along) I employ to counter the 6 F's from Dr. Howard Schubiner ( Six F’s - Fear, Focus, Fix, Frustration, Figuring It Out and Fight) that turn the volume dial up on pain. And by the end I discover the 5th S - SUPPORT!
Article about the Twin Peaks of Pain -
https://longevitypt.com.au/blog/how-to-explain-chronic-pain/
[00:00:00] Welcome to the curiosity cure podcast. I'm your host, Deb Malkin, master certified life coach, body worker, hypnotist trained in pain reprocessing by the pain psychology center, queer elder fat human on planet earth here to help you evoke the power of simple neuroplasticity techniques rooted in shame, free curiosity.
[00:00:29] So you can feel more better. More of the time in the body you have today and build the rich, full life that you want to live. A quick disclaimer. This podcast is not a replacement for medical care. I am here to provide insights and techniques that can compliment your healthcare journey, but always consult with your healthcare provider for personalized advice.
[00:00:56] Hello, my feelers and healers. Welcome to the curiosity cure podcast. I am your host, Deb. And this episode is the second part of my reflection on my trip and my knee pain. I'm going to call this one, post flare care. Because it's going to cover all the ways I'm approaching physically and mentally a pain flare. and possible injury through a mind body approach, which I highly recommend for anyone navigating anything unpleasant with your body, because it incorporates both pain neuroscience, as well as nervous system regulation and soothing.
[00:01:36] It's essential that we don't only put fixing the pain at the center of our mind body experience. Dr. Howard Schubiner, leading mind body physician, researcher, and my teacher has a framework called the six F's, fear, focus, fix, frustration, figuring it out and fight as a reminder of what not to do when dealing with pain.
[00:02:03] Because our attention drives much of what our brain decides is important and amplifies due to high arousal emotions and a protective mechanism. This list is a simple touchstone for changing our habitual responses. And this comes from Dr. Schubiner's book, Unlearn Your Pain. So this is a quote, fear of the pain or other symptom.
[00:02:29] We, we fear the sensation of it as it can be so severe and unpleasant. We worry about when it will go away or when it will return. We spend a lot of time wishing it will go away.
[00:02:43] Focus on the pain or other symptom. We pay a lot of attention to it. We monitor it. We focus on how it feels and if it's changing or getting worse. Frustration with it. We get upset, annoyed, and angry at the pain or other symptom. We become resentful that doctors haven't fixed it or don't understand it. We become sad for what we have lost.
[00:03:08] Fighting it. We work hard to overcome it. We try to push through it and we get exhausted in the fight, especially where we feel like we're losing the battle. Trying to figure it out. We spend a lot of time thinking about it. We search for answers online, in doctor's offices, and with alternative care practices, trying to fix it. We spend a lot of time and money on treatments that haven't worked.
[00:03:35] We try anything and everything that might work. We get desperate for a cure. We get depressed when one doesn't materialize. So I did a lot of these Fs. I did with this knee pain, not a lot, but like, sure, some of it. And it's certainly things that I have recognized about myself in the past. So not saying there's anything abnormal about responding to your pain this way.
[00:04:02] But when I recognize that my brain was falling into fear, fixation, fixing, frustration, and fighting. and figuring it out. I took that as my cue to do what I think of as the antidote, the four S's. Soften, soothe, settle, and surrender. Maybe I'll discover more S's as I go along. So soften, The impulse behind softening is to treat myself, especially when I'm hurting with utmost care and compassion, countering any feeling of urgency with the opposite feeling like time is expansive and what is going on after an assessment, of course, that it isn't urgent, shifting into relaxing.
[00:04:54] Softening. The next S is soothe. So specific techniques like a hand on my heart and a hand on my belly or gently holding my face or imagining I'm being held by a force larger than me and noticing if there are any self critical voices arising, ones that want to poke me with blame and shame. And just thinking about soothing those self critical voices and caring for the me that is having this experience.
[00:05:29] And then settle. I think of settling as orienting to the present moment, not settle as in settle for less, but settle as in settling my state or my nervous system. Orienting to the present moment looks like my, I notice practice, I notice my body is feeling X. And I noticed my thoughts and my feelings are . It could be doing a somatic tracking practice. Could be noticing everything that's not the pain, broadening out my sense of self to more than what I'm hyper focused on. And then surrendering for me on this trip, that meant doing one thing at a time, letting go of the desired outcome and making sure that I could sense into safety and strength when possible and letting go of the rest, surrendering to what is, and letting that be complex and more than one thing.
[00:06:29] And as I talked about in the last podcast, being willing to feel disappointed, I think that's a part of surrender to the next day. I'm picking this up, uh, still on my trip. The next day after the missed snorkeling trip to Los Tuneles was a boat trip back to Santa Cruz and I felt like, okay, buddy, it might be a challenge to get on and off those taxi boats, but we are going to do our best.
[00:06:59] And it actually went much better than I expected. I had definitely practiced doing some mental rehearsal of getting on and off the boat safely. So that really allowed me to move slowly and surely and not be moving with that sense of fear and panic, which often will, uh, make us move faster than we feel comfortable.
[00:07:22] And especially if we're dealing with issues of balance, you don't really want to be moving fast, uh, if you are afraid. So really just getting that sense of like sure step, being able to safely reach out and hold the person's hand, and arm who is helping support me and just really noticing What if I'd like to plant my feet and take the step and take the next step and then take the next step?
[00:07:58] The rest of that day was a free day to explore shopping or sightseeing. We had a lovely brunch and then some of us went off shopping and to see some cool mosaics. And I would stay with a group when I was feeling okay, and then I would break off and sit or gently wander when my body was asking for that.
[00:08:19] But one thing I noticed was that the more I walked at a leisurely pace, the more things loosened up and my gait became more and more normal. I still didn't know what that meant, but all the variation I took as a good sign. We walked back to the hotel and decided that we wanted to explore the beach near the Charles Darwin Research Center. Playa De La Estacion. We got changed and hopped in a cab and there was still some walking, but the beach was easy to manage and we got some snorkel gear from friends who were there before us. And we got to see some more sharks and swimming iguanas and more sea lions lounging on the beach. And just.
[00:09:03] enjoyed the buoyancy and ease of the water. That was this kind of a remedy feeling of really being able to feel, how good it felt to just be in the water and be held by the water. I definitely was taking it easy. Unlike the snorkeling that we did with the fins, like I definitely used my arms more and I was just being very mindful of My knee.
[00:09:31] The next day It was our flying home day and all throughout I had some pain coming and going, but I was going home and I was where I was going to hopefully be able to book an appointment with an orthopedic doctor. I was sad that the trip was over and was still working through processing disappointment and a little fear.
[00:09:52] When I think about pain now, I consider different things than just tissue damage or ideas like bone on bone, which can't but help sound incredibly scary. Hyperfixation, sensitization, and threat assessment are all key components of pain amplification or having high intensity of sensation. So what if this is all like a stereo and a volume dial?
[00:10:22] And using this mind body approach, we can turn down the volume on the dial. Sometimes we can turn it down so much that it's at a zero. And if it's at a zero, is there still pain? So really just being able to notice Where is this dial and thinking of it more as a volume dial rather than a pain scale? And that the number on the scale relates to a particular thing happening inside of the tissue.
[00:10:57] Part of what's really powerful for me in understanding this stuff as I'm thinking about volume, you know, all the myriad ways that I can to invite that volume to be turned down. I was talking about in the last podcast, the concept of the twin peaks of pain. And so this is an article I'm going to read to you a little bit.
[00:11:21] From this article from Longevity PT in Australia, uh, and they have a part of their piece is how to explain chronic pain. There are many ways to explain chronic pain. The most important thing is to emphasize that pain is not an indicator of tissue damage. It is a learned, protective indicator. response by the brain to protect the body from potential danger.
[00:11:48] As the body is now in a state of fight or flight, that protective system becomes hypervigilant. What is also important to note as a practitioner explaining pain is that the pain the patient feels is very real. So it is important to make sure that they feel that their experience is understood and validated.
[00:12:09] One analogy to best explain this hypervigilant response is the Twin Peaks model. In this model, your protect by pain line falls just below your tissue tolerance. When experiencing chronic pain after the aggravating event, your tissue tolerance line has decreased slightly. However, the protect by pain threshold decreases drastically, meaning the gap between where something causes pain to where it causes tissue damage is a lot greater.
[00:12:49] So let me see if I can explain this better. And there's a, A great graphic. So if you click through to the article, you'll see the graphic. So in general, for people who do not have chronic pain or who do not have a hypervigilant, protective response. Your protect by pain line, which is the, the message from your body before there is tissue damage.
[00:13:15] So I love to use this analogy that if you have your hand over a hot stove, you'll start to feel it before there's tissue damage, right? And that is meant to inspire you to move your hand, right? So it's protecting you from tissue damage with pain. After you've experienced chronic pain, after an aggravating event, your tissue tolerance line might have decreased slightly.
[00:13:44] So that means your tissue tolerance is not the same necessarily as it was before an aggravating event. But the protect by pain threshold decreases drastically. So the protect by pain message gets triggered a lot sooner, well before approaching this, uh, tissue tolerance line.
[00:14:11] All of a sudden we're getting, uh, protect by pain messages, but we're not anywhere near any kind of tissue damage. So we're just wanting to understand that's how the brain learns systems of protection and we can use this mind body approach to start to get the brain a little bit less sensitive and protective. Especially once we believe that like healing has happened.
[00:14:44] Another phenomenon that occurs is called brain smudging. So usually pain, like all sensations is localized to a specific area, cause damage to that area and that area will feel pain. Each area of the body is also represented by a specific area in the brain, like a map. So when there is a feeling of pain. The brain knows exactly where it's coming from and how to fix it. When the brain feels extra protection is required for the affected area, sometimes it will involve neighboring areas to help protect it.
[00:15:19] So a stimulus applied to those areas can also become painful. What happens over time is the borders on the map become blurred. And when pain is experienced, it can be hard to tell exactly where the pain is coming from, causing a sensation of the pain radiating. Sometimes when people notice that like their pain is growing, we'll see this a lot in fibromyalgia. So maybe somebody had some hand pain or a little bit of wrist pain and then all of a sudden they have forearm pain and elbow pain and then shoulder pain. We can see that this smudging experience is happening and it's part of our protection system. So the reason it's important Back to the article to explain pain is that understanding one's pain is an important step to manage that pain.
[00:16:12] Pain is typically an indicator of tissue damage. However, in patients with chronic pain, the association between pain and tissue damage becomes less and less. So, it is important to understand that distinction. An important step is to decrease the reliance on scans and imaging results, as these don't always provide the most reliable indication of function.
[00:16:38] When patients are reassured of not causing further damage to their body when they experience pain, it can help them work into their pain, pushing that protect by pain line a little higher. Bye. During exercise, it's important to include a component of pain education as exercise is so important for everyone and often one of the first things to be impacted by pain.
[00:17:04] Usually there are two kinds of attitudes when it comes to exercising with chronic pain. The first is an overly protective attitude where the client is so cautious of pain They avoid any stimulus that might cause pain. The second is an overly determined attitude where patients become fixated on quote unquote beating their pain, working well past their protect by pain threshold, resulting in a flare up that leaves them incapacitated.
[00:17:35] In both cases, the amount of activity the body can tolerate decreases and that protect by pain line drops. lower and lower. So this is why sometimes people feel a flair after doing things because they are working past that protect by pain threshold. So we need the mind and body approach to help decrease that threshold. So with chronic pain patients, activity pacing becomes important.
[00:18:10] By exercising the patient around that protect by pain line and increasing activity gradually, it demonstrates to them that a little pain is okay and you avoid flare ups that may leave the patient incapacitated and unable to exercise. It is also better to use language like tolerable and intolerable when getting clients to describe their pain rather than severity, as everyone's perception of severity is different, so it can be an unreliable measure.
[00:18:44] However, when properly pacing activity, flare ups can still occur. It is important to reassure the patient that this is a normal part of the pain experience and that you have measures in place to help them manage those flare ups. Ultimately, what is most important is that the patient feels exercising with pain is safe and that you create an environment that is supportive.
[00:19:10] When the patient feels safe, it helps bring them out of the fight or flight state, helping them to manage, if not overcome, their pain, end quote.
[00:19:21] I did manage to get an appointment with an orthopedist, which was really delightful. I actually managed to do three medical things that week. I got a mammogram. I went to this orthopedist appointment and I got a shingle shot.
[00:19:34] So it was a super self care week. The orthopedist took some x rays. He listened to my story. He also listened to my complaints about the chairs in the waiting room that didn't accommodate plus size people. He calmly told me that my x rays reflected mild to moderate osteoarthritis, which I was already aware of.
[00:19:54] He said I wasn't conclusive for a meniscus tear and that they didn't necessarily require surgery. He said they only have three treatment options. medication, injections, and PT. I chose PT because my pain was so intermittent by this point that I didn't feel the need to medicate or treat it away.
[00:20:16] He didn't say or do anything that gave me the idea that healing was not possible for me. And that recovering from this pain was not possible for me. One of the things that this doctor didn't do, that my last doctor did was paint a picture of how my knee pain was only going to get worse and worse year after year.
[00:20:37] He didn't do that. He didn't paint this terrifying picture, which a previous doctor who I had trusted had done. This doctor was calm and hopeful. He said, we can do PT and then revisit in a few months. And what a difference in the attitude and approach. I didn't have to deal with a doom and gloom scare scenario being painted by someone that I needed help from.
[00:21:05] So I've started doing PT with a one on one practitioner, she came highly regarded. I knew I wanted to work with one skilled person, if possible, rather than the usual system where they're working with more than one person at a time. She's giving me some challenging quad strengthening activities. I get to share my story with her as well as my fears and worries.
[00:21:28] One of her first responses was, Oh my God, the Galapagos, how fun. And that was a really nice thing to hear that she didn't just only focus on what's wrong, but really just saw me as a whole person. So we had a first great session experience. And then I did a bunch of stairs, going up and down the subway, which felt fantastic when I did them.
[00:21:53] And then the next day I had a little flare up and I I wrote to her and I said, Hey, I just had a little flare up. She wrote me a very supportive note. When I reflected my worry, I said, good morning, Deb. While we both know nothing heals overnight. And you told me right out of the gate that you often do great and then have a little setback.
[00:22:14] So while it's unfortunate, it's also not surprising to me that your knee pain returned and joint stiffened, particularly if you suddenly navigated far more stairs than you might normally on any given day. Everything with recovery is fine lines and learning how to push limits without overdoing it. While flare, gentle, passive, pain free range of motion is always the best bet for your condition. She was suggesting gentle heel slides. And if it's stiff, but not feeling too inflamed. I could try using heat if I wanted to. She said, it's about finding the right balance for what your body likes and responds to.
[00:22:54] Keep the faith, keep up with the quad work, a little smiley emoji base. You'll be amazed at how far that will take you. Those words also helped me settle and feel soothed. Especially because by the time I got them from her, I had already started to feel better. So my flare was coming down. Yes, there's a flare, but then there's also the recovery from the flare. And so maybe another S is for support, enlisting the right kind of support to help create a foundation for healing both tissue healing and nervous system pain amplification healing. Uh, it was really helpful to have somebody skilled and kind to tell me what kind of exercises to do.
[00:23:43] And to my surprise, I am doing them pretty consistently. And each time I contract my quad, I'm really focusing on the success of that movement. I'm also doing some visualization work around sit to stand and with my walking gait, so that I'm training my brain to do the movements I want to do in the way that I want to do it, and I'm spending some time with my massage skills, working the tissues around and behind the knee, sometimes thinking of the pain gate theory, it's this idea that only one sensation can kind of be experienced at a time. So I'll rub my knee or my leg to create a pleasurable sensation to focus my attention on instead of only experiencing this part of my body as other.
[00:24:31] As the enemy or the broken part. My leg that is healing is just as much a part of me as anything else. And if I need support from other people, my knee needs the support from me. Instead of feeling separate from myself, I now feel like my best ally. This story will continue, I imagine, as long as I have knees.
[00:24:56] I've got another trip coming up in a few weeks and I'm hopeful to have a good baseline of both strengthening and also confidence and having an approach that isn't about feeling perfect, but one that is about having some unpleasant sensations and having the skills and knowledge to work with them. If persistent pain or fear about pain is something that you deal with and find you would like help navigating these experiences, please book a curiosity call with me.
[00:25:25] I'm here to help you get back to adventuring in your today body with all the tools to help you navigate whatever arises. Thank you so much for listening. Take care.